The Modernising Patient Pathway Symptomatic Breast Speciality Group has been established to support and look at new innovative ways to develop delivering Symptomatic Breast services across NHS Scotland.

Through development of Once for Scotland approaches for delivery of care, focus is being placed on looking at opportunities to develop clinical pathways to reduce unwarranted variation in delivery of quality healthcare and to sustainably improve waiting times for non-urgent care within breast services. Speciality Delivery Groups have been established to engage and fully utilise the role of clinical leadership across NHS Scotland.

Development of the Breast Skin Problems Pathway has been progressed through MPPP speciality group as was a common theme identified during meetings held with colleagues across NHS Scotland. The recommendations have not followed the standard process used by SIGN to and are based on available guidance and expert opinion, with peer review to provide quality assurance.

This guidance will be reviewed and updated as new evidence emerges.

Consensus

A common theme during the Breast Speciality Delivery group meetings has focused on the referral of women with breast skin issues to secondary care services.

A consensus was formed around the principles that:

The majority of breast skin issues are innocent and most can be managed without referral to secondary care.

1. Specific breast imaging is not required outwith screening if examination of breast tissue is normal on examination.

2. Skin itch, scaling and redness (often affecting areola)

1. Eczema of the breast is common and often presents with itch, redness, skin thickening and scaling of the skin, often affecting the areola. The skin can become raw and weep. This should be distinguished from discharge from the milk ducts of the nipple.
2. It can be managed as eczema elsewhere on the body.
3. If cases fail to settle with local steroid or similar changes are present affecting the nipple itself, patients should be referred to the breast service to exclude Paget’s Disease of the nipple.
4. If there is doubt in the breast clinic regarding the nature of a skin condition, a punch biopsy should be performed.

3. Redness of skin

1. Patchy and variable erythema of the skin of the breast is common and usually entirely innocent.
2. Reassurance is usually all that is required.
3. Inflammatory breast cancer occurs when lymphatic channels with the breast are obstructed. This results in oedema and erythema of the breast often with a palpable mass and/or palpable lymph nodes. It is rare but concern should prompt urgent referral to the breast service.

4. Skin cysts

1. Skin cysts affecting the breast area are common, particularly affecting the underside of the breast and axilla.
2. Patients should be encouraged to stop smoking and lose weight.
3. Acute infection should be treated with appropriate antibiotics.
4. Significant abscesses may be referred to secondary care.
5. Discharging abscesses can be managed with dressings and often do not require referral.
6. Persistent troublesome individual lesions may be referred to secondary care for consideration of elective excision.
7. A constellation of lesions under the breast or the axilla (with the groins often also affected) is due to hidradenitis suppurativa. Surgical management of this condition is discouraged and referral through dermatology pathways may be considered.

5. Skin cancer

1. Skin cancer can affect the breast and suspected cases can be referred through dermatology pathways.

Scottish Referral Guidelines for Suspected Cancer. www.cancerreferral.scot.nhs.uk

   gjnh.cfsdpmo@gjnh.scot.nhs.uk

  www.nhscfsd.co.uk

@NHSScotCfSD

Centre for Sustainable Delivery

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